Healthcare Provider Details

I. General information

NPI: 1821174707
Provider Name (Legal Business Name): JAY WUNG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 01/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 OAK ST SE
SALEM OR
97301-4020
US

IV. Provider business mailing address

PO BOX 351769
LOS ANGELES CA
90035-0226
US

V. Phone/Fax

Practice location:
  • Phone: 503-814-7441
  • Fax:
Mailing address:
  • Phone: 310-867-4653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA83271
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD28768
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: